Tracheal Rupture Following Blunt Chest Trauma Presenting As Endotracheal Tube Obstruction Cynthia L

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Tracheal rupture following blunt chest trauma presenting as endotracheal tube obstruction Cynthia L. Henderson MD FRCPC, Scan R. Rose MD FRCPC

In this report, we describe a patient in whom a tracheal tear In all trauma cases, basic rescucitation begins with the followed blunt thoracic trauma. 1he diagnosis was made late establishment and maintenance of an adequate airway. resulting in problems with ventilation, endotracheal tube ob- If blunt thoracic trauma has occurred, one should always struction and cardiac arrest. Difficulties with early recognition consider the possibility of concomitant tracheal injury. of tracheobronchiai injuries may be caused by non-specific find- Unfortunately, more common injuries associated with ings as well as the lack of exposure of physicians to patients trauma may produce similar findings and divert one's with these injuries. The signs and symptoms of tracheobronchial attention from the less frequent tracheobronchial trauma. injuries are described, as well as their differential diagnoses. The following case demomtrates the importance of a A review of airway management has been made as it requires high index of suspicion in making the diagnosis of tra- combined anaesthetic and surgical expertise. Injuries of the tracheobronchial injury following blunt trauma to the chest. chea may have severe, life-threatening consequences and early diagnosis and management reduce morbidity and mortality. Case report A 64-yr-old man was evaluated following blunt chest Cette observation d~crit I'~,volurion d'un patient victime d'une trauma. A hydraulic garbage container fell, crushing his d~chirure trach~ale d la suite dim traumatisme thoracique chest between the container and the ground. The patient fermd. Des probl~mes ventilatoire~, une obstruction de la canule and a co-worker lifted the container and the patient endotrach~ale et un arr~t cardiaque ont orient~ vers ce dia- walked home. He presented to the Emergency Depart- gnostic. La difficult~ de reconnattre prdcocement une blessure ment of a community hospital two hours later with trach~obronchique peut provenir aussi bien de ia non sp~cificit~ respiratory distress and hypotension. His trachea was des sympttmes que de l'exp~rience du mddecin qui traite ce intubated, intermittent positive-pressure ventilation com- type de blessure. Lea signes et sympttmes des blessures tra- menced and he received adrenaline. Bilateral chest tubes chd,obronchique$ sont d~taill~s ainsi que le diagnostic diffdren- were inserted because of the potential for tension pneu- tiel. On attire l'attention sur la gestion des voies a~riennes qui mothoraees. n~cessite autant de comp&ence de la part de l'anesthdsiste que After stabilization he was transferred and evaluated du chirurgien. Les blessures d la tmch~e peuvent avoir des r$per- by the Trauma Service. At that time, his blood pressure cussions graves et le diagnostic et une gestion prdcoces en r$dui- was low at 80/50 rnrnHg and femoral arterial and venous sent la morbidit~ et la mortaliM. lines were inserted for diagnosis and management. The portable chest x-ray taken on admission revealed a pneumomediastinum, bilateral multiple rib fractures, bilateral chest tubes with no pneumothoraces, and ex- Key words tensive subcutaneous emphysema along the chest wall. AIRWAY" obstruction; The endotracheal tube was in a good position. A Com- COMPLICATIONS: trauma; puter Assisted Tomography (CT) Scan in Emergency LONG: trachea, rupture. showed a large pneumomediastinum, subcutaneous air, From the Department of Anaesthesia, St. Paul's Hospital, and a right pneumothorax. The patient was transferred 1081 Burrard Street, Vancouver, B.C. VtZ IY6 and the to the Surgical Intensive Care Unit haemodynamically Department of Anaesthesia, Peace Arch Hospital, 15521 stable. On arrival, his blood pressure decreased to 80/ Russell Avenue, Whiteroek, B.C. V4B 2R6. 50 mmHg and a needle thoracostomy was performed Address correspondence to: Dr. Cynthia L. Henderson. followed by the insertion of two additional chest tubes. Acceptedfor publication 19th May, 1995. The patient's condition worsened and his oxygen satu-

CAN J ANAESTH 1995 / 42:9 / pp Sl6-9 Henderson and Rose: TRACHEAL RUPTURE 817 ration decreased. His lungs became more difficult to ven- tilate and increased resistance was noted when manually ventilating them with an Ambu bag, ruling out problems with the mechanical ventilator. A suction catheter was passed easily down the endotracheal tube beyond the tip and a large blood clot was removed. His ventilation improved but his blood pressure decreased to 70 mmHg systolic and he developed electromechanical dissociation (EMD). CPR was initiated. Before the arrest, the patient had received 7 L crystalloid in the SICU and, thus, hy- povolaemia was not considered to have caused the EMD. The differential diagnosis included tension pneumothorax and pneumomediastinum, cardiac tamponade, myo- cardial contusion and hypoxia. Epinephrine 1 mg/v was given which increased the systolic blood pressure to 120 FIGURE CT scan showing endotracheal tube (arrow) outside the mmHg. Bronchoscopy was performed immediately and tracheal lumen. a tracheal tear was found. The endotracheal tube was inserted past the tear under direct vision and the patient's condition quickly stabS. The patient was transferred to the operating room or chest during motor vehicle accidents accounts for 80% where he was found to have an almost complete dis- of injuries to the larynx or the tracheobronchial tree 2 ruption of the distal trachea. The continuity of the trachea and early diagnosis and management reduce the mor- had been maintained by a 5 mm portion of membranous bidity and mortality from tracheobronchial tears.3-s Fol- trachea in the midline of the posterior tracheal wall. lowing non-penetrating trauma, other intrathoracic inju= Anaesthesia was maintained with isoflurane, opioids, and des are much. more common than tracheobronchial muscle relaxants using ,positive-pressure ventilation. At injuries. Delays in diagnosis may occur because the signs the level of the innominate artery, 3-0 Vicryl was used are non-specific and these injuries axe infrequent. in an interrupted fashion to suture the trachea. The endo- Clinical manifestations depend upon the location and tracheal tube was left in position with the cuff inflated extent of the tear as well as on the associated injuries. below the tear during the tracheal repair. Following the Nearly 10% of patients are asymptomatic but the majority repair, the endotracheal tube was pulled back until the present with dyspnoea, haemoptysis and/or cyanosis. ~ tip lay proximal to the suture line to miniunz"e pressure Other common symptoms may be subtle and include lo- on the repair site. cafized pain, hoarseness, coughing, difficultyswallowing Postoperatively the patient continued to have a stormy and stridor.Massive hacmopWsis indicates an associated course. The following day he had a traumatic false aneu- vascular injury and not an isolated tracheal or bronchial rysm of the aortic arch repaired which was found on injury,t Signs inchde bruising or swelling of the neck, review of the initial CT scan, The patient required tracheal deviation, abnormal breath sounds, tension positive-pressure ventilation for two weeks postoperatively pneumothorax, hypotension, cardiovascular collapse and due to rib fractures, pulmonary contusions and Adult Hamman's sign, a crunching sound synchronous with the Respiratory Distress Syndrome before being successfully heart beat.~ Subcutaneous emphysema is the most con- weaned from the ventilator. At the time of discharge from sistcnt physical finding,s Pneumopcritoncum, usually the Surgical Intensive Care Unit, the chest x-ray showed associated with perforation of a viscus, has been described an elevated left hemidiaphragm with bilateral plettral ef- rarely. 9 Acute symptoms may resolve with emergency fusions. He was discharged home 19 days post-injury with treatment only to return in days or weeks once stenosis no apparent sequelae. develops at the site of injury, to Our patient presented When the initial CT scan was reviewed, higher cuts with respiratory distress and hypotension of unknown ae- showed the endotracheal tube inside the traeheal lumen tiology. but, just above the carina, the distal tip was clearly out- Chest and neck x-rays are essential to verify an air side the lumen (Figure). leak and may reveal free air that is not detectable on physical examination. Cervical and thoracic subcutaneous Discussion emphysema are the most consis."tent radiological findings Traumatic injuries of the tracheobronchial tree range in tracheal injuries caused by blunt trauma; however, they from asymptomatic to fatal, i Blunt trauma to the neck are more commonly seen as nonspecific fmdings in the 818 CANADIAN JOURNAL OF ANAESTHESIA acute trauma patient after multiple rib fractures, pene- these patients. Direct laryngoscopy may cause further trating chest wounds, or a difficult intubation. H Subcu- deterioration in airway patency and intubation may result taneous emphysema that persists or increases should raise in the distal endotracheal tube lying outside the tracheal the suspicion of a continuing air leak from an airway lumen, as in this case. Preferably, intubation is performed injury, although disappearing emphysema does not rule using fibreoptic bronchoscopy as guidance to visualize out an airway tear. H Pneumomediastinum is an early the injury. If the tear involves the trachea, the cuff of diagnostic sign but may also be a complication of dysp- the endotracheal tube should be positioned below the in- noea, aggressive mechanical ventialtion or oesophageal jury, if possible. If a main bronchus is involved, the tube rupture. If the tear is in the right main bronchus or the may be inserted into the main bronchus of the unaffected distal left bronchus, the air will usually be seen in the side. ~ Double lumen tubes have been used to improve pleural space creating a pneumothorax. However, if the ventilatory function, facilitate intraoperative airway man- trachea or proximal left main bronchus is involved the agement and permit selective postoperative ventilatory air will commonly dissect centrally producing mediastinal support; however, there may be difficulty in proper place- and cervical emphysema. 12 Failure to re-expand the lung ment, further airway injury may result, and suctioning with a chest tube under suction should increase the sus- may be inadequate, s An endotracheal tube with a mov- picion of a persistent leak from an airway injury. Other able blocker (Univent) has been used perioperatively to radiological findings associated with airway injuries in- block the injured bronchus. 17 Bronchoscopic examination clude upper thoracic fractures of the clavicles, scapula, or intubation attempts may lead to complete tracheal tran- sternum or ribs, air surrounding a bronchus and inter- section or obstruction of the airway, therefore, preparation ruption, sharp angulation or obstruction of the airways. for immediate tracheostomy must be made before either Specific radiological evidence of tracheobronchial injury is attempted. Is Patients with complete tracheal transec- includes abnormal appearance of the endotracheal tube tion, laryngeal injuries or considerable airway obstruction such as overdistension of the cuff and extraluminal po- may require tracheostomy under local anaesthesia. Tra- sition of the tip and the "fallen lung sign" which occurs cheostomy may be necessary if the patient undergoes when the affected lung collapses toward the lateral chest rapid deterioration or if the trachea cannot be quickly wall or diaphragm rather than the hilum. H The chest and successfully intubated. Js A transected trachea usually x-ray of our patient revealed pneumomediastinum, bi- retracts into the mediastinum necessitating the use of a lateral multiple rib fractures, bilateral chest tubes with finger to locate the divided end of the distal trachea that no pneumothoraces, and extensive subcutaneous emphy- should be grasped with a clamp to pull it into view, and sema, all of which may be associated with trache0bron- to allow intubation, is Ventilation may be maintained via chial injury or simply other intrathoracic injuries. a rigid bronchoscope while evaluating the airway injury. 16 In the diagnosis of injury to the tracheobronchial tree If available, femoral-femoral bypass under local anaes- following blunt trauma, CT scan has become an impor- thetic may be instituted if attempts to secure the airway tant adjunct. 13 It can aid the physician in those injuries fail. which produce subtle radiographic findings on plain fdms The operative management of tracheobronchial tears of the chest and neck. In our case, CT scan findings is dependent on the site of injury and repair is usually not seen on chest x-ray included a non-e.xpanding pneu- performed via thoracotomy. Originally it was felt that mothorax in spite of bilateral chest tubes. The CT scan an inhalational agent with spontaneous ventilation would demonstrated the endotracheal tube tip outside the tra- be beneficial intraoperatively as it would allow lower air- chea although it appeared in good condition on the plain way pressures. 19 It is advisable not to use nitrous oxide fdrn. which can expand pre-existing air collections. 2~ When Bronchoscopic examination is the most valuable di- positive-pressure ventilation is mandatory, high peak air- agnostic and potentially therapeutic technique for acute way pressures should be avoided by either ventilating by injuries t3-15 and should be performed early in concert hand, using small tidal volumes at higher rates, or em- with other diagnostic, resuscitative and therapeutic ef- ploying pressure support ventilation. High frequency ven- forts. ~0 The findings may be clear but more often bron- tilation has been used to improve alveolar ventilation with ehoscopy is technically very difficult secondary to bleed- decreased peak airway pressure, decreased tidal volume, ing from the parenchyma or torn tracheobronchial and decreased air leak, and avoids an inflated endo- mucosa. Bronchography, usually contraindicated because tracheal tube cuff against the suture line. 21 of the general condition of the patient, may miss small Postoperatively the endotracheal tube should be pulled tears and should be reserved for chronic cases in which back above the repair site if the trachea cannot be ex- stenosis or occlusion may have occurred. ~0 tubated. Airway pressures should be minimm"ed to avoid Airway management is of paramount importance in stress on the suture lines. Henderson and Rose: TRACHEAL RUPTURE 819

Conclusions 8 Shimazu T, Sugimoto H, Nishide K, et al. Tracheobron- Trauma to the intrathoracic tracheobronchial tree is a cilia] rupture caused by blunt chest trauma" acute respira- rare but potentially fatal injury. Physicians must maintain tory management. Am J Emerg Med 1988; 6: 427-34. a keen vigilance and have a high index of suspicion of 9 Barnhan GR, Brooks JW, Kellum JM. Pneumo- a tracheobronchial tear with blunt chest trauma. We de- peritoneum resulting from tracheal rupture followingblunt scribe a patient with a history of blunt chest trauma who chest trauma. J Trauma 1986; 26: 486-8. presented with hypotension and respiratory distress. The 10 Nakayama DK, Rowe ML Intrathoraeic tracheobmnchial patient's chest x-ray showed pneumomediastinum, rib injuries in childhood. Int Anesthesiol Clin 1988; 26: 42-9. fractures, and subcutaneous emphysema. Further findings 11 UngerJM, Schuchmann GG, Grossman Jl~ Pellett JR. on CT scan included a non-expanding pneumothorax in Tears of the trachea and main bronchi caused by blunt spite of bilateral chest tubes as well as the endotracheal trauma" radiologic findings. American Journal of Roent- tube tip outside the tracheal lumen. In spite of these find- genology 1989; 153: 1175-80. ings, the diagnosis of tracheobronchial injury was not 12 Guest JL Jr, Anderson JN. Major airway injury in dosed entertained until after the patient had difficulties with ven- chest trauma. Chest 1977; 72: 63-6. tilation, endotraeheal tube obstruction, and cardiac ar- 13 Palder SB, Shandling B, Manson D Rupture of the tho- rest. A high index of suspicion may have prevented these racic trachea followingblunt trauma: diagnosis by CAT problems and addressed the primary pathology sooner. Scan. J Pediatr Surg 1991; 26: 1320-2. Patients with a history of blunt chest trauma and findings 14 Burke JF. Early diagnosis of traumatic rupture of the suggestive of airway injury including mediastinal emphy- bronchus. JAMA 1962; .181: 682-6. sema or haemoptysis should undergo early bronchoscopy. 15 Westaby S. Injury to the major airways. Br J Hosp Med A critical evaluation of the patient clinically, radiolog- 1985; 34: 210-20. ically, and bronehoscopieally should lead to earlier di- 16 Symbas PN, Justicz AG, Ricketts RR. Rupture of the air- agnosis resulting in improved airway management and ways from blunt trauma: treatment of complex injuries. lower morbidity and mortality of tracheal and bronchial Ann Thorae Surg 1992; 54: 177-83. injuries. 17 St. Cyr JA, Fullerton DA, Zamora M, Hopeman AR. Traeheobmnehial disruption: postoperative management Acknowledgment with jet ventilation to minimize airway pressures. J Cardio- Assistance from Dr. C. Brian Warriner in reviewing the vase Surg 1994; 35: 79-81. manuscript is gratefully acknowledged. 18 Ayabe H, Tsufi A, Akamine S, Tagawa Y, Kawahara K~ Tomita M. Combined trameetion of the trachea and References esophagus followingcervical blunt trauma. Thorae Cardio- 1 Kelly JP, Webb WR, Moulder PV, Everson C, Burch Btt, vase Surg 1993; 41: 193-5. Lindsey ES. Management of airway trauma I: Tracheo- 19 Santora AH, Wroe WA. Anesthetic considerations in trau- bronchial injuries. Ann Thorac Surg 1985; 40: 551-5. marie tracheobronchial rupture. South Med J 1986; 79: 2 Grover FL Ellestad CE, Arom KV, Root HI), Cruz AB, 910-1. lh'nkle JK. Diagnosis and management of major traeheo- 20 Feinstein R, Owens WD Anesthesia for ear, nose, and bronchial injuries. Ann Thorac Surg 1979; 28: 384-91. throat surgery. In: Barash PG, Cullen BF, Stoelring RK. 3 Eijgelaar A, van der Heide JNH. A reliable early symp- (Eds.). Clinical Anesthesia, 2nd Ed. Philadelphia: JB Lip- tom of bronchial or tracheal rupture. Thorax 1970; 25: pineott, 1992:1122. 120-5. 21 Dreyfuss D, Jackson RS, Coffin LH, Dearie RSD, Shino- 4 Chavez CM, Arms P,, Conn JH. Surgical approach to in- zaki T. High-frequency ventilation in the management of juries of the cervical trachea. South Med J 1972; 65: tracheal trauma. J Trauma 1986; 26: 287-9. 659-60. 5 Meinke AH, Bivins BA, Sachatello CR. Selective management of gunshot wounds to the neck. Am J Surg 1979; 138: 314-9. 6 Chesterman JT, Satsangi PN. Rupture of the trachea and bronchi by closed injury. Thorax 1966; 21: 21-7. 7 Palmer MT, Turney SZ. Tracheal rupture and atlanto- occipital dislocation: case report. J Trauma 1994; 37: 314-7.